Fact, Fiction, or Fable: Deciphering Medicare Payment, Regulations, and Rules

Rick Gawenda, PT
Founder and President, Gawenda Seminars & Consulting, Inc.

Speaker Bio

Date: Saturday, September 29, 2018
Time: 10:30 AM to 12:30 PM
Instruction level: Intermediate


Providing outpatient therapy services to Medicare beneficiaries continues to cause providers confusion and headaches due to the complexity of Medicare rules and regulations—as well as some urban legend myths that can cost therapy practices their hard-earned dollars. This session aims to provide clarity on Medicare rules and regulations for outpatient rehab therapy providers on such topics as:

  • Current payment rates of popular CPT codes
  • Individual vs. group therapy
  • The continued use of the KX modifier
  • Risk of medical record review for Medicare claims exceeding $3,000
  • Use of the ABN for therapy services
  • PTA and student supervision
  • Billing for patient education and how to bill more than four timed units in an hour
  • Scheduling and productivity


  1. Identify which CPT codes have a higher payment rate compared to other CPT codes.
  2. Explain the chances of a medical record review for Medicare claims exceeding $3,000 in a calendar year.
  3. Define PTA, OTA, and student supervision requirements for Medicare and commercial insurance carriers.
  4. Discuss how you can bill more than four time-based CPT code units in an hour.
  5. Differentiate when it is and is not appropriate to issue an ABN to a Medicare beneficiary.